PART 1 - PATIENT CONTACT INFORMATION. PART 2 GENERAL Questions
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1 PART 1 - PATIENT CONTACT INFORMATION Name: Status: Address: City: Province: Postal Code: Date of Birth: Occupation: Children: Home Phone: Work Phone: Cell Phone: Address: I agree to be on Clinic Maintenant s mailing list. PART 2 GENERAL Questions 1. Most patients are referred to our clinic by a caring family member or friend. What made you decide to visit our clinic? Website Presentation Sign - Passing by Family member or friend Name: 2. Research shows that your spine should be checked regularly. How many times have you consulted a chiropractor? 3. When was your last complete spinal examination? 4. Spinal tension causes decay and degeneration which results in grinding or cracking. Do you ever hear noises when you move your head or neck? 5. Spinal tension can make you feel like you need to twist, stretch or crack your neck or back. Do you ever feel the need to crack or pop your neck or lower spine? 6. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture? (Poor Excellent) PAGE 1/13
2 PART 2 - GENERAL QUESTIONS (CONT D) 7. Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days. (Low High) Prescription medication may cause serious side-effects, hide the severity of health problems and hinder the body s ability to heal. What medication are you currently taking? 9. Car accidents and work-related injuries can cause serious damage to the spinal cord. Are you consulting our clinic because of a work-related injury or accident? If, please write the date when it occurred : PART 3 YOUR SYMPTOMS AND HOW THEY CAN INFLUENCE YOUR LIFE 1. Do you have a current health/life concern or symptom? If, please describe: When did it begin? How and why did it manifest itself? If, please describe the reason you are consulting our clinic and then skip directly to PART 4: 2. Is your problem a work-related accident or due to a road-accident? If yes, please write down the date of the accident: PAGE 2/13
3 PART 3 - YOUR SYMPTOMS AND HOW THEY CAN INFLUENCE YOUR LIFE (CONT D) 3. Have you done anything about this concern or been given any advice or treatment for it? If, describe what was done. 4. Have any other family members had the same or similar concerns? If, what did they do about it? Did it seem to work? 5. How aware are you of your symptom / concern in the morning when you get up? (0 = not at all / 3 = extremely aware) 6. How aware are you of your symptom / concern during the day? (0 = not at all / 3 = extremely aware) 7. How aware are you of your symptom / concern at the end of the day? (0 = not at all / 3 = extremely aware) 8. How are are you of your symptom / concern during the night? (0 = not at all / 3 = extremely aware) 9. Is there an activity that you do, during which you totally, or almost totally forget about this condition? 10. Why do you think this is happening, or continues to happen to you? 11. Do you think this is the only reason? If, what else may be the cause? PAGE 3/13
4 PART 3 - YOUR SYMPTOMS AND HOW THEY CAN INFLUENCE YOUR LIFE (CONT D) 12. Are you doing anyhting differently in your life because of this symptom / concern? If, please describe: 13. If it were to go away tomorrow, how would your life be different? 14. Please grade how the concern / symptom affects the folllowing aspects of your functioning or quality of life: (0 = does not seem to affect me, 1 = slightly affects me, 2 = moderately affects me, 3 = extremely) Work Recreation Rest / sleep Social life Walking Sitting position Exercising Eating Relationships Comments: 15. If the situation didn t change or evolve, how do you think it would affect your life in the next 5 years? 16. If we could work together to help you solve this problem, how would your life be different in the years to come? PAGE 4/13
5 PART 4 - PHYSICAL STRESS HISTORY 1. Your Birth Did your mother experience any problems during her pregnancy with you? Check all that apply: Falls Illness Difficult Not sure Comments: Was your birth... Check all that apply: Traumatic Cesarean Breech Forceps or suction Cord around the neck Prolonged Very fast Natural Induced Home Hospital Birthing Centre 2. Falls Check all that apply, indicating age and year: Crib / Carriage Stairs On ice Jungle gyms Skiing / Snowboarding Other falls (Please describe.) From a tree 3. General Physical Trauma Check all that apply, indicating age and year: Lost consciousness Use of crutches or a cane Broken bones or sprains (Describe): Combat Physical fights Sports Extensive dental work / Orthodontics Other (Describe): PAGE 5/13
6 PART 4 - PHYSICAL STRESS HISTORY (CONT D) 4. Accidents (big or minor, either as a driver or passenger) Check all that apply indicating age and year : Car Motocycle Bus Train Bike Airplane Other: Comments: 5. Daily Activities Check all that apply : Sitting Standing Walking Desk work Phone Sports Exercising Computer work Watching TV Driving / Commuting Playing an instrument Reading for long periods Mechanical work Heavy lifting Contacts Glasses Comments: 6. Medical History Check all that apply, indicating age and year : Hospitalisation - Reason? Surgery - Why? Chemotherapy Radiation Corrective shoes, bars, lifts Physiotherapy Spinal taps, injections Comments : Casts or corsets Spinal / Neck Brace PAGE 6/13
7 PART 4 - PHYSICAL STRESS HISTORY (CONT D) 7. Have you or a family member ever suffered a serious illness? 8. Do you have a family doctor? 9. When was your last medical exam? Please write the date of the exam: What were the results? 10. (For women.) Are you pregnant? If, please indicate the number of weeks: PAGE 7/13
8 PART 5 - CHEMICAL STRESS HISTORY 1. Birth Stress During your mother s pregnancy, did she : Check all that apply : Use prescription drugs Use non-prescription drugs Smoke Consume alcohol / drugs I don t know 2. During your birth, was your mother : Check all that apply : Conscious Semi-conscious Unconscious Given spinal anesthesia Given chemicals to alter or induce labour I don t know 3. General Chemical Stress : Are you taking or have you ever taken : Check all that apply : Prescription drugs Over-the-counter drugs Antibiotics Other drugs Tobacco 4. List all current and past medication and include reasons and length of time you were taking them. 5. Do you work with or have you worked with or ever been exposed to : Chemicals Fumes Dust Powder / particles Smoke Other substances 6. Do you consume : Alcohol Coffee / caffeine Processed food Artificial sweetners Refined sugar Sodas Tap water 7. Describe your diet : PAGE 8/13
9 PART 6 - EMOTIONAL STRESS HISTORY 1. Were you incubated or isolated after birth? 2. Were you : Bottle-fed Nursed Both 3. Past General Emotional Trauma Check all that apply and note the severity (mild, moderate or extreme) : PAST PRESENT MILD MODERATE EXTREME Childhood Personal relationship Change of job / career School Divorce / separation Change of lifestyle Recreational Work-related Commuting Loss of loved-one Parents divorce Abuse Family Financial Stress of being sick / ill Comments : PAGE 9/13
10 PART 7 - LIFESTYLE PROFILE 1. How would you rate your emotional mental health? Excellent Good Fair Poor Getting better Getting worse 2. How would you rate your overall quality of life? Excellent Good Fair Poor Getting better Getting worse 3. Have you pursued other avenues of growth, healing or personal development? Check all that apply : Chiropractic Acupuncture Massage / Bodywork Homeopathy Psychotherapy Ayurvedic Medecine Osteopathy Physical Therapy Aromatherapy Energy Work Rebirthing Sound / Light Therapy 4. What aspects of your life do you like, bring you joy or help you to feel better about yourself? 5. What particular factors or elements about your life experiences (family, work, recreational, past injuries, genetics, dietary programs, exercises, outlook, etc.) do you feel impair your opportunity to experience full health and wellness? 6. Which of the following do you practice regularly? Exercise - Times per week : Yoga - Time per week : Chi Gong - Times per week : Movement / Dance - Times per week : Meditation - Times per week : Prayer - times per week : 7. List any herbs, nutritional supplements or natural remedies you regularly take: 8. When stressed, how do you centre yourself or re-group? PAGE 10/13
11 PART 8 - WELLNESS AND QUALITY OF LIFE SURVEY (CONT D) 1. Physical State How often do you experience the following symptoms : Physical pain (neck/back ache, sore arms/legs, etc.) Feeling of tension, stiffness or lack of flexibilty Fatigue, lack of energy NEVER RARELY occasionally Regularly constantly Colds, flu Headaches Heartburn, indigestion Nausea, constipation Menstrual discomfort Allergies, skin rashes Dizziness, light-headedness Accidents, near accidents, falling or tripping Ease of recovery from injury Restricted or shallow breathing 2. Mental / Emotional State Rate the following questions in terms of frequency : Feelings of distress when pain is present Negative or critical feelings about yourself Moodiness, temper flare-ups or outbursts of anger never rarely occasionally regularly constantly Feelings of depression, lack of interest Over-reacting to life stresses Being overly worried about small things Feelings of vague fears or anxiety Difficulty thinking or concentrating or indecisiveness Difficulty falling asleep or staying asleep Experience of recurring thoughts or dreams PAGE 11/13
12 part 8 - wellness and quality of life survey (cont d) 3. Stress Evaluation Evaluate your stress with respect to the following : Family none slight moderate Considerable extensive Significant Other Physical Health Finances Sex Life Work or School Coping with daily problems 4. Life Enjoyment Rate the following statements with respect to frequency : Openness to guidance from your inner voice or intuition Experience of peace, relaxation, ease or well-being Presence of positive thoughts about yourself Interest in maintaining a healthy lifestyle Feeling of being open, aware and connected when relating to others NEVER RARELY OCCASIONALLY REGULARLY CONSTANTLY Confidence in your abilty to deal with adversity Level of compasison for and acceptance of others Experience feelings of joy or happiness Experiencing gratitude Satisfaction with your sex-life Satisfaction with your leisure activities Time dedicated to the things that you like to do PAGE 12/13
13 5. Overall Quality of Life Evaluate your feelings with respect to your quality of life : Your personal life unhappy mainly dissatisfied mostly mixed satisfied happy Your wife/husband or significant other Your romantic life Your job Your co-workers The work you actually do Handling problems in your life What you are actually accomplishing in your life Your physical appearance - the way you look Your abilty to adapt to change in your life Overall contentment with your life PAGE 13/13
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